Jain Ashok, Nalesnik Mike, Reyes Jorge, Pokharna Renu, Mazariegos George, Green Michael, Eghtesad Bijan, Marsh Wallis, Cacciarelli Thomas, Fontes Paulo, Abu-Elmagd Kareem, Sindhi Rakesh, Demetris Jake, Fung John
Thomas E. Starzl Transplantation Institute, the Divisions of Transplantation Surgery and Transplantation Pathology, and the Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213, USA.
Ann Surg. 2002 Oct;236(4):429-36; discussion 436-7. doi: 10.1097/00000658-200210000-00005.
To evaluate the incidence of posttransplant lymphoproliferative disease (PTLD) and the risk factors and the impact of this complication on survival outcomes in a large cohort of liver transplant recipients at a single institution.
Liver transplantation has been accepted as a therapeutic option for patients with end-stage liver disease since 1983, in large part due to the availability and reliance on the use of nonspecifically directed immunosuppression. However, as predicted and subsequently verified in 1968, an increased incidence of certain de novo malignancies has been observed, particularly with regards to lymphoid neoplasms. While many reports have confirmed and clarified the nature of PTLD, the literature is fraught with conflicting experience and outcomes with PTLD.
Four thousand consecutive patients who underwent liver transplants between February 1981 and April 1998 were included in this analysis and were followed to November 2001. The effect of recipient age at the time of transplant, recipient gender, diagnosis, baseline immunosuppression, grading of PTLD, and association with Epstein-Barr virus were compared. The causes of death were also examined. Treatment for PTLD varied over the 20-year period, but all included massive reduction or elimination of baseline immunosuppression.
The 1-year patient survival for liver transplant patients with PTLD was 85%, while the overall patient survival for the entire cohort was 53%. The actuarial 20-year survival was estimated at 45%. The overall median time to PTLD presentation was 10 months, and children had an incidence of PTLD that was threefold higher than adults. Patient survival was better in children, in patients transplanted in the era of tacrolimus immunosuppression, in patients with polymorphic PTLD, and in those with limited disease. Interestingly, neither the presence or absence of Epstein-Barr virus nor the timing of PTLD presentation appeared to influence overall patient survival. Patients transplanted for alcohol-related liver disease had a similar incidence of PTLD but had a higher risk of mortality.
While PTLD continues to pose problems in patients receiving liver transplants, improvements in patient survival have been observed over time. While it is too early to assess the impact of new advances in prophylaxis, diagnosis, and treatment, such approaches are based on an increased knowledge of the pathophysiology of PTLD.
评估在一家机构的大量肝移植受者队列中，移植后淋巴细胞增生性疾病（PTLD）的发病率、危险因素及其对生存结局的影响。
自1983年以来，肝移植已被公认为终末期肝病患者的一种治疗选择，这在很大程度上得益于非特异性定向免疫抑制的可用性和依赖性。然而，正如1968年所预测并随后得到证实的那样，已观察到某些新发恶性肿瘤的发病率有所增加，尤其是淋巴样肿瘤。虽然许多报告已证实并阐明了PTLD的性质，但关于PTLD的文献充满了相互矛盾的经验和结果。
本分析纳入了1981年2月至1998年4月期间连续接受肝移植的4000例患者，并随访至2001年11月。比较了移植时受者年龄、受者性别、诊断、基线免疫抑制、PTLD分级以及与EB病毒的关联的影响。还检查了死亡原因。在这20年期间，PTLD的治疗方法各不相同，但所有治疗方法都包括大幅减少或消除基线免疫抑制。
患有PTLD的肝移植患者1年生存率为85%，而整个队列的总体患者生存率为53%。精算20年生存率估计为45%。PTLD出现的总体中位时间为10个月，儿童PTLD的发病率比成人高3倍。儿童、在他克莫司免疫抑制时代接受移植的患者、患有多形性PTLD的患者以及疾病局限的患者的患者生存率更高。有趣的是，EB病毒的有无以及PTLD出现的时间似乎都不影响总体患者生存率。因酒精性肝病接受移植的患者PTLD发病率相似，但死亡风险更高。
虽然PTLD在肝移植患者中仍然是一个问题，但随着时间的推移，患者生存率有所提高。虽然评估预防、诊断和治疗方面的新进展的影响还为时过早，但这些方法是基于对PTLD病理生理学的更多了解。
